HomeMy WebLinkAboutAPPLICATION PLUMBING - 19-00056 - 642 Trejo StC I TY OF
REXBURG
Amrricui Family Community
BUILDING PERMIT FORM 13 i
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BUILDING APPLICATION
Remodel SFR Plumbing
Building Safety Department
City of Rexburg
35 North 1st East
Rexburg, Idaho 83440
Permit Number: ❑ Plumbing Fee Paid
Name: PJ
Address: f),5r) W 4 ,, Affr) &s4 city: �_hrx 1AI; G State: _ Zip Code:
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Phone: SCA- t-�96- j Email: 'Ac k ki 1 1 unA das i un (Jib M
Under Idaho Building Code, a homeowner is allowed to do work on their own home.
Are you a homeowner doing work on your own home?
❑ Yes (Skip to and complete the Homeowner's Exemption)
12 No, I am working with the homeowner
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Business: "" i l 1.�. ,,, t. , Mate Licens #:, Q�3 p 4 Exp.: _�'� 1- Z63
Address: Q City: A 0 h 6 tv I I tate: Zip Code:
Phone z T _ Email � G�
Contact/Rep. Name: Pho : _ 'AM -0_ Email:
Plumbing Contractor Authorized Signature: Date:
A copy of your state reclistration/license is required to be on file, if s' e first timeyou have done work in the City i t?exhurg, qleA!deaprov
a photo copy of your license. Ifyou are unsure ifyour license is on file. please check with the Permit Technician by calling (208) 372-2341.
Prow( -t Description
Address: -s+_
Description of work W -.
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• Fees for remodels are charge by cost:
o First $10,000 = 296 +$60. From $10,000 to $100,000 = 196 + $260. Above $100,000 =.5% +$1,160. i.e. Work costing
$15,000 will be charged $60 for the first $10,000 and 1 % of the remaining $5,000 = $60 + $50 = $110 total fee
APPLICANT'S SIGNATURE, CERTIFICATION AND AUTHORIZATION: Under penalty of perjury, I hereby certify that I have read this application and state that the information herein
Is correct and 1 swear that any Information which may hereafter be given by me In hearings before the Planning and Zoning Commission or the City Council for the City of Rexburg
shall be truthful and correct 1 agree to comply with all City regulations and State laws relating to the subject matter of this application and hereby authorized representatives of the
City to enter upon the above-mentioned property for Inspections purposes. NOTE: The building official may revoke a permit on approval Issued under the provisions of the 2012
International Code in cases of any false statement or misrepresentation of fact in the application or on the plans on which the permit or approval was based. Permit void if not
started within 180 days. Permit void if work stops for 180 days.
Applicant's Name (print): 054 �"Lwww Signature: Date: 1-(0-V1
Inspections must be called in before 8 AM on the day the inspection is requested. Inspection requests called In after 8 AM will be scheduled for the next business day.
Inspection Hotline - (208) 372.2344 www.rexburg.org Permit Technician - (208) 372.2341